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Acil Servise Nöbet Şikayeti ile Başvuran Olguların Görüntüleme Bulgularının Analizi
No full textObjective: In this study, our aim was to evaluate the imaging findings of patients admitted to the emergency department with seizures during the period of January 2009 – July 2017.
Material and method:1002 patients with an admission diagnosis of seizure during the period of January 2009 – July 2017 were included in this study. After the evaluation of medical records, 202 of them were excluded due to a final diagnosis of syncope or inability to differentiate syncope from seizure. Features including age, gender, established diagnosis of epilepsy, new-onset seizure and coexisting disease (neoplastic and non-neoplastic) were determined for all patients. The patients were analyzed in two groups: new-onset seizure cases and cases with a history of epilepsy. Both groups were further stratified according presence or absence of a medical history; patients with medical history were classified into neoplastic and non-neoplastic groups; neoplastic ones were categorized into intracranial and extracranial neoplasms, intracranial neoplasia into primary central nervous system (CNS) neoplasia and metastasis, and primary CNS neoplasias into glioblastoma and other intracranial neoplasms. Patients with non–neoplastic medical disease history were stratified according to involvement of CNS. Patients with disorders involving the CNS were classified as vascular and non-vascular pathologies. Patients with history of epilepsy were divided into two groups: primary/idopathic and secondary symptomatic epilepsies. History of trauma was specifically noted in patients with history of epilepsy and primary/idiopathic seizures. Imaging techniques (CT and MRI) obtained during the admission were reviewed. Positive finding on CT and MRI was considered as new pathology (diagnostic) or as a finding that would change therapy and/or follow-up plan (prognostic). The distribution of imaging findings across clinical categories was then assessed and odds ratios in patients with epilepsy and new onset seizures were calculated. The diagnostic yield of imaging, especially for pathologies that were not evident on CT but apparent on MRI was also evaluated. For patients with multiple admissions, separate odds ratios were determined for initial admission and repeated scans.
Results: The average age of the patients was 46.7±19.7 years. Among 800 patients, 458 (57.3%) were male and 342 (42.7%) were female. 38.9% (n=311) of patients were admitted to the hospital with new-onset seizure, while 61.1% (n=489) already had a seizure history. 40.5% of the patients suffering from their first seizure were found to have a positive medical history. The location of neoplasms in the group of new-onset seizures was extracranial in 74% and intracranial in 26 %. The most common extracranial neoplasm was primary lung cancer. However, among primary intracranial neoplasms glioblastoma was the most common (33.3%), followed by meningioma and low grade glial tumors. Cerebrovascular accident (CVA) was the most common cause of non-neoplastic disorders affecting CNS with a rate of 26.5%, intracranial aneurysms were the next common cause and was observed in 14.7% of cases. The incidence of abnormal imaging findings was significantly high in the following cases: new-onset seizure history (p<0.001), neoplasm, extracranial neoplasm, especially when there is a history of non-metastatic lung cancer, other extracranial neoplasm presence except for lung cancer (p<0.001), intracranial neoplasm (p=0.001) except for glioblastoma and newly diagnosed non-neoplastic disease (p=0.011).
57.7% of patients with epilepsy had primary epilepsy and 42.3% had secondary symptomatic epilepsy. 58 of patients with primary epilepsy (11.9 % of all epilepsies) had a trauma accompanying the seizure while being admitted to the hospital. 23.5% of patients with secondary symptomatic epilepsy had a history of neoplastic disease, while 18.8 % of them had non-neoplastic disease history. All neoplasms were intracranial in patients with secondary symptomatic epilepsy. 65.2% of these tumors were primary CNS tumors and 34.8% of them were intracranial metastasis of extra-CNS tumors. The rate of primary intracranial neoplasms was as follows: 29.7% glioblastomas, 18.9% meningioma, 16.2% oligodendroglioma. CVA (15.2%) was the most common cause of non-neoplastic disease in secondary symptomatic epilepsy patients, followed by previous epilepsy surgery (12%) and AVM (12%). The incidence of positive imaging findings among secondary symptomatic epilepsy patients was high in the presence of neoplasm (p=0.023) and glioblastoma (p=0.030). The incidence of positive imaging findings in patients with history of primary epilepsy was low (p<0.001).
75% of patients with negative CT and positive MRI findings had anew onset seizure, while, 25% of them were in the group of patients with epilepsy history. A great majority of findings on MRI were arterial ischemia, meningits-encephalitis and venous ischemia in this group of patients. 46.7% of patients admitted to the hospital multiple times had primary epilepsy, while 53.3% of them had secondary epilepsy. None of the patients admitted on multiple occasions had any pathology on CT or MRI. There was also no significant increase in the incidence of positive findings in the secondary symptomatic epilepsy group, as well.
While the sensitivity of CT in new onset seizure with the history of neoplastic (extracranial and intracranial) disease was 65-80% depending on the size of lesion and the patophysiology of co-existing non-neoplastic pathology, it was lower than 35% in both vascular and non-vascular pathologies in non-neoplastic group. The sensitivity of CT in secondary symptomatic epilepsy patients with neoplasm (intracranial and extracranial) was 75-100%, while it was between 35-65% in patients without neoplasm and higher than in patients with new onset seizure.
Conclusion: In conclusion, the incidence of positive finding on imaging that will change the diagnostic, therapeutic or follow-up process is higher in the group of patients with new onset seizure. The yield of CT was high in both new onset seizure and secondary symptomatic epilepsy patients, and also in patients with history of an underlying disease. If there is a history of non-neoplastic, especially vascular pathology associated disease in the newly diagnosed and secondary symptomatic epilepsy patients using MRI together with CT during admission or follow-up will be helpful for diagnostic, therapeutic and follow-up processes. Patients presenting to emergency department with seizure and with primary epilepsy history do not show an increase in the incidence of positive findings on imaging. The presence of trauma history in the patients with primary epilepsy increase the incidence of positive finding on imaging, but without statistical significance.Amaç: Çalışmamızda, Ocak 2009 - Temmuz 2017 tarihleri arasında hastanemiz erişkin acil ünitesine nöbet şikayeti ile başvuran olguların görüntüleme bulgularını analiz etmeyi amaçladık.
Gereç ve yöntem: Ocak 2009 - Temmuz 2017 tarihleri arasında erişkin acil servise nöbet şikayeti başvuran toplam 1002 hasta başvurusu çalışmaya alındı. Klinik verilerin değerlendirilmesi sonucu senkop-nöbet ayrımı yapılamayan veya senkop tanısı alan 202 başvuru çalışma dışı bırakıldı. Hastalarda yaş, cinsiyet, bilinen epilepsi, yeni tanı nöbet ve bilinen hastalık varlığı (neoplastik ve non-neoplastik gibi) araştırıldı. Hastalar, yeni tanı nöbetler ve bilinen epilepsiler olmak üzere iki alt grup halinde değerlendirildi. Her iki grup hastalar, hastalık öyküsü olup olmamasına göre, hastalık öyküsü olanlar ise neoplastik ve non-neoplastik olmasına göre, neoplastik hastalık öyküsü olan hastalar intrakraniyal ve ekstrakraniyal, intrakraniyal neoplaziler primer santral sinir sistemi (SSS) neoplazileri ve metastazlar, primer SSS neoplazileri ise glioblastom ve diğer intrakraniyal neoplaziler olarak iki grupta sınıflandırıldı. Non-neoplastik hastalık öyküsü olan hastalar SSS’ni etkileyen patolojiler ve SSS’ni etkilemeyen patolojiler olarak iki grupta sınıflandırıldı. SSS etkilenimi olan hastalar vasküler ve vasküler olmayan patolojiler olarak sınıflandırıldı. Bilinen epilepsi öyküsü olan hastalar primer/idiopatik ve sekonder edinsel olarak iki gruba ayrıldı. Primer/idiopatik öyküsü olan bilinen epilepsi hastaları ise travma öyküsü olan ve olmayan diye iki grupta sınıflandırıldı. Sonrasında ise hastaya uygulanan görüntüleme tetkikleri (BT ve MRG) değerlendirildi.Hastalarda görüntülemede pozitif bulgu, BT ve/veya MRG’de, yeni patoloji varlığı (diagnostik) veya mevcut olan patolojide tedavi ve/veya takip planını değiştirecek (prognostik) bulgular olarak kabul edildi. Görüntüleme bulguları yukarıda tariflendiği gibi analiz edildikten sonra klinik parameterler ile oluşturulmuş sınıflama ile karşılaştırılarak, yeni tanı nöbet ve bilinen epilepsi hastalarında, alt gruplar için Odds ratio (tahmini rölatif risk) analizi yapıldı. Radyolojik görüntülemenin tanısal etkinliği, BT’in negatif MRG’in pozitif bulunduğu hastalarda görüntülemede saptanan patolojiler ve saptanan patolojilerin sıklığı değerlendirildi. Hastaneye birden çok kez başvuran hastaların genel başvuru dağılımı, tekrarlanan görüntülemede pozitif bulgu varlığına göre Odds ratio (tahmini rölatif risk) değerlerinin analizi yapıldı.
Bulgular: Hastaların ortalama yaşı 46,7±19,7 yıl olup, 458’i (%57,3) erkek, 342’si (%42,7) kadın olmak üzere toplam 800 başvuru çalışmaya dahil edildi. Araştırmaya alınan hastaların %38,9’u (n=311) ilk kez nöbet geçirme şikâyeti ile hastaneye başvurmuş iken, %61,1’inde (n=489) nöbet geçmişi bulunmaktaydı. İlk kez nöbet geçiren hastaların %40,5’inde hastalık öyküsü (%23,8’i neoplastik ve %16,7’si non-neoplastik) varken; yeni tanı nöbet ile başvuran ve bilinen neoplazisi bulunan hastaların %74,0’ında ekstrakraniyal, %26,0’ında ise intrakraniyal neoplazi hikayesi mevcuttu. En sık görülen ekstrakraniyal neoplazi ise primer akciğer kanseriydi. Primer intrakraniyal neoplazi türleri incelendiğinde, en sık glioblastoma (33.3 %), sonra sırasıyla menenjiyom ve düşük dereceli glial tümörlere rastlanmıştır. SSS’ni etkileyen non-neoplastik patolojilerde %26,5 oran ile SVO en sık neden iken, bunu %14,7 oran ile intrakraniyal anevrizmalar takip etmektedir. Görüntülemede pozitif bulgu görülme sıklığı yeni tanı nöbet öyküsü (p<0,001), altta yatan hastalık varlığında, neoplazi varlığında, ekstrakraniyal neoplazi varlığında, özellikle non-metastatik akciğer kanseri öyküsü, akciğer kanseri dışı diğer ekstrakraniyal neoplazi varlığında (p<0,001), glioblastom dışı diğer intrakraniyal neoplazi varlığında (p=0,001) ve yeni tanı non-neoplastik hastalık varlığında (p=0,011) anlamlı olarak yüksek bulundu.
Bilinen epilepsi hastaların %57,7’si primer epilepsi hastası, %42,3’ü sekonder edinsel epilepsi hastasıdır. Primer epilepsi olan hastaların 58’inde (tüm bilinen epilepsilerin %11,9’u) başvuru anında nöbete travma eşlik etmektedir. Sekonder edinsel epilepsili hastaların %23,5’inde neoplastik; %18,8’inde ise non-neoplastik hastalık öyküsü vardı. Sekonder edinsel epilepsi hastalarında neoplazilerin tamamı intrakraniyaldi. Bu tümörlerin %65,2’si primer SSS tümörü iken, %34,8’i intrakraniyal metastaz yapan SSS dışı neoplazilerdir. Primer intrakraniyal neoplazilerin en büyük kısmını %29,7 ile glioblastom oluştururken, onu %18,9 ile menenjiyom, %16,2 ile oligodendrogliom takip etmektedir. Sekonder edinsel epilepsi hastalarında non-neoplastik hastalıklarından en sık neden SVO (%15,2) olup bunu, geçirilmiş epilepsi cerrahisi (%12,0) ve AVM (%12,0) takip etmektedir. Sekonder edinsel epilepsi grubunda görüntülemede pozitif bulgu görülme sıklığı neoplazi varlığında (p=0,023), glioblastom varlığında (p=0,030) anlamlı olarak yüksek bulundu. Primer epilepsi öyküsü olan hastalarda ise pozitif bulgu görülme sıklığı anlamlı olarak düşük bulundu (p<0,001).
Patoloji varlığının BT’de negatif, MRG’de pozitif olduğu hastaların %75’i ilk nöbet ile başvuran hasta grubunda, %25’i ise bilinen epilepsi grubundadır. BT’de negatif, MRG’de pozitif bulgusu olan tüm hastalarda MRG’deki bulguların büyük çoğunluğunu arteryal iskemi, menenjit-ensefalit ve venöz iskemi oluşturmaktadır. Hastaneye birden çok başvuran hastaların %46,7’si primer epilepsi, %53,3’ü ise sekonder epilepsi hastasıdır. Birden çok başvurusu olan primer epilepsi hastalarının hiçbirinde BT veya MR’de patoloji saptanmamıştır. Tekrar gelen sekonder edinsel epilepsi hasta grubunda pozitif bulgu görülme sıklığında anlamlı artış izlenmedi.
Yeni tanı nöbet hastalarında BT'nin patoloji saptamada duyarlığı neoplastik (ekstrakraniyal ve intrakraniyal) hastalık öyküsü olanlarda lezyonun boyutuna, eşlik edebilecek non-neoplastik patolojinin patofizyolojisine göre %65-80 arasında değişmekte olup, non-neoplastik grupta hem vasküler hem de non-vasküler patolojilerde BT'nin duyarlılığı %35'in altındadır. Sekonder edinsel epilepsi grup hastalarda BT'nin patoloji saptamada duyarlılığı neoplazi grubunda (intrakraniyal ve ekstrakraniyal) %75-100 arasında değişmekte olup, non-neoplazi grubunda yeni tanı nöbet grubu ile karşılaştırıldığında yüksek bulunsa da %35-65 arasında değişmektedir.
Sonuç: Çalışma sonucunda görüntülemede diagnostik, tedavi ve takip sürecini değiştirecek patolojik bulgu (pozitif bulgu) görülme sıklığı yeni tanı nöbet hasta grubunda daha yüksektir. Hem yeni tanı nöbet hem de sekonder edinsel epilepsi tanısı olan, altta yatan neoplastik hastalık öyküsü olan hastalarda BT'nin etkinliği yüksek bulundu. Yeni tanı ve bilinen sekonder edinsel epilepsi grubundaki hastalarda non-neoplastik özellikle de vasküler patolojilerle ilişkili hastalık öyküsü mevcut ise BT ile birlikte MRG modalitesinin başvuru anında veya takip görüntülemede kullanılması hastanın tanı, tedavi ve takip sürecindeki değişiklerin yönetilmesinde yardımcı olacaktır. Nöbet yakınması ile acil servise başvuran hastalarda bilinen primer epilepsi öyküsü görüntülemede pozitif bulgu görülme sıklığını artırmamaktadır. Primer epilepsi öyküsü olan hastalarda eşlik eden travma öyküsünün de olması görüntülemede pozitif bulgu görme sıklığını anlamlı derecede olmasada arttırmaktadır
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Author Under Sail The Imagination of Jack London, 1893-1902
No full textIn Author Under Sail, Jay Williams offers the first complete literary biography of Jack London as a professional writer engaged in the labor of writing. It examines the authorial imagination in London's work, the use of imagination in both his fiction and nonfiction, and the ways he defined imagination in the creative process in his business dealings with his publishers, editors, and agents. In this first volume of a two-volume biography, Williams traverses the years 1893 to 1902, from London's "Story of a Typhoon" to The People of the Abyss. The Jack London who emerges in the pages of Author Under Sail is a writer whose partnership with publishers, most notably his productive alliance with George Brett of Macmillan, was one of the most formative in American literary history. London pioneered many author models during the heyday of realism and naturalism, blurring the boundaries of these popular genres by focusing on absorption and theatricality and the representation of the seen and unseen. London created an impassioned, sincere, and extremely personal realism unlike that of other American writers of the time. Author Under Sail is a literary tour de force that reveals the full range of London as writer, creative citizen, and entrepreneur at the same time it sheds light on the maverick side of machine-age literature.Intro -- Title Page -- Copyright Page -- Dedication -- Contents -- Acknowledgments -- Introduction -- 1. Spirit Truth -- 2. From Absorption to Theatricality and Back Again -- 3. "I Will Build a New Present" -- 4. Sons as Authors -- 5. Fathers as Publishers -- 6. The Daughter as Author -- 7. Lovers as Authors -- 8. At Sea with the Family -- 9. Yellow News, Yellow Stories -- 10. The Return Home -- Notes -- Bibliography -- Index -- About Jay WilliamsIn Author Under Sail, Jay Williams offers the first complete literary biography of Jack London as a professional writer engaged in the labor of writing. It examines the authorial imagination in London's work, the use of imagination in both his fiction and nonfiction, and the ways he defined imagination in the creative process in his business dealings with his publishers, editors, and agents. In this first volume of a two-volume biography, Williams traverses the years 1893 to 1902, from London's "Story of a Typhoon" to The People of the Abyss. The Jack London who emerges in the pages of Author Under Sail is a writer whose partnership with publishers, most notably his productive alliance with George Brett of Macmillan, was one of the most formative in American literary history. London pioneered many author models during the heyday of realism and naturalism, blurring the boundaries of these popular genres by focusing on absorption and theatricality and the representation of the seen and unseen. London created an impassioned, sincere, and extremely personal realism unlike that of other American writers of the time. Author Under Sail is a literary tour de force that reveals the full range of London as writer, creative citizen, and entrepreneur at the same time it sheds light on the maverick side of machine-age literature.Description based on publisher supplied metadata and other sources.Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, YYYY. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries
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